Publisher's Note: When additional information and perspectives become available over the coming days and weeks, we will continue to update this post. As a news organization, we believe it is our duty to share varying viewpoints without bias in order to give readers insights into different vantage points regarding the nation's delivery system and access to care.

The process to repeal the Affordable Care Act has begun. While Republicans have been unified in their call to repeal President Barack Obama's signature healthcare legislation, the steps forward to "replace" that coverage for nearly 20 million Americans have not enjoyed such singular clarity. On Thursday, Jan. 12, the U.S. Senate voted on a budget measure that put procedures in place to begin dismantling ACA. The U.S. House followed with a vote on Friday. While the votes were cast largely along party lines, a number of Republican senators and representatives have expressed concern over repealing the act without having a replacement in place. President-elect Donald Trump also has called for simultaneous repeal and replace and, over the MLK weekend, said the replacement should include "insurance for everybody."

As the entire nation watches to see what happens to the Affordable Care Act under the Trump administration, the Tennessee Medical Association has releasedspecific recommendationsits physician members believe can improve the quality and efficiency of healthcare in the U.S.

The state's largest professional organization for doctors conducted a thorough analysis of specific provisions that help improve patient care and lower costs, and other elements of the ACA that can and should be improved.

"Our Board of Trustees feels it is important for physicians to take a leadership role in defining and communicating what is best for patients," said TMA President Keith G. Anderson, MD of Memphis. "Important decisions being made in Washington will affect how healthcare is delivered and paid for in Tennessee, and across the U.S. Tennessee physicians should have a voice in that process."

The controversial ACA generated some notable gains its proponents lauded, such as increased access to health insurance for Americans, but was also wrought with problems and unintended consequences for patients and physicians. In its policy, TMA offers six recommendationsfor President Trump and Congress to consider as they explore a potential repeal and replacement of the ACA.

Reduce barriers to patients receiving care, including prohibiting healthcare insurance companies from denying coverage for preexisting conditions, reinstituting lifetime benefit limits on coverage for some patients, and allowing families to keep children on their plans up to age 26.

Make wellness a major focusby eliminating out-of-pocket charges for preventive care, training more primary care physicians, reining in the cost of drugs and creating more physician-led medical homes and health homes.

Pay for quality while reducing unnecessary regulatory and administrative requirements for healthcare providers, and stimulating the use of information technology.

Give states more flexibility to expand health insurance coveragein the form of block grants they can use to design and implement programs that best fit each state's population.

Increase and improve end of life careby requiring reimbursement for doctors who have conversations about advance directives, and increasing grant funding for physician education and training.

TMA is among the most influential healthcare voices in the Tennessee General Assembly, and actively advocates for physicians and their patients at the federal level. The organization is committed to making sure healthcare policies and regulations come that come down from the federal government lead to accessible, affordable, quality healthcare in Tennessee.

Governors Share Their Thoughts

The National Governors Association released a letter the evening of January 24 in response to a request for feedback on ACA reform from the states' chief executives.

Editor's Note: THCC Board President Clare Sullivan, who penned the statement below, references Sen. Lamar Alexander's bridge analogy in her piece. Scroll down for that original information from the senator, as well as thoughts from other stakeholders.

The Tennessee Health Care Campaign (THCC) has been advocating for affordable, accessible and quality healthcare for over 27 years. THCC staff and volunteers support the fundamental framework of the Affordable Care Act (ACA) that guarantees coverage, makes insurance options more transparent and affordable, and is transforming health care payment systems to improve health outcomes and control costs. But we also recognize from our work in communities across the state that further improvements to the ACA are needed, especially to help control the costs of coverage and care.

We want to acknowledge our Senators Lamar Alexander and Bob Corker for their reasoned efforts to delay repeal of the Affordable Care Act (ACA) until effective options can be enacted. Senator Alexander likened the challenge of replacing the ACA to one that a community might face if an essential bridge was in danger of collapsing. Rather than demolish that bridge and force the community to wait years until a new one was built with all the economic disruption that would cause, it would be necessary to shore up and repair the existing bridge until a new one could be constructed to take its place.

To continue this ACA-as-bridge metaphor, it is important to question whether the bridge needs actually needs replacement or could be restored with well-engineered repairs. Is damage to the bridge due perhaps to construction and maintenance issues rather than the design of the bridge itself? In contrast to many other states where the ACA Marketplaces function more effectively, Tennessee never finished building the ACA bridge according to the original specs.

Instead of working with the ACA-linked federal option to expand coverage (to) hundreds of thousands of Tennesseans earning near or below the national poverty level, the Tennessee legislature chose to totally forego that federal funding (now up to $2.9 billion lost dollars) that would have covered no less than 90% of the expansion, and could have been invested in the physical and mental health of our citizens and the economic health of our communities. Hundreds of thousands of uninsured Tennesseans fell through that self-inflicted gap in the bridge, and are forced to delay needed care, resulting in more costly and uncompensated care that further weakens our state's health care infrastructure. At this time it is not at all clear whether any closing of the coverage gap will be possible in Tennessee if ACA defunding is accomplished.

Our state's reluctance to correct deliberate misinformation about the Affordable Care Act has hindered hundreds of thousands of working Tennesseans who have been eligible to enroll in the ACA from doing so. These policies have further contributed to the instability of that bridge, by promoting "adverse selection" in the Tennessee ACA markets (meaning those who are experiencing risks to their health are more likely to enroll than those who are healthier, driving up the overall cost of care). Determination to repeal the individual mandate to have health insurance, which is akin to a toll most citizens understand is needed to gain access to and maintain essential public services, would implode the foundation of the ACA bridge beyond repair and guarantee that a more costly replacement would become the only option.

On this day, let's recall another bridge, where Americans stood their ground on behalf of our civil rights. Dr. King, who said 'Of all the forms of inequality, injustice in health care is the most shocking and inhuman,' recognized access to healthcare as one of those fundamental rights. We urge our Senators to stand firm to protect our right to health and healthcare, and seek ways to strengthen, and widen, this indispensable bridge.

Clare Sullivan MSN, MSPH, Board President, THCC

THA's Viewpoint

Tennessee Hospital Association CEO Craig Becker released a statement on Thursday, Jan. 12 calling for repeal to be followed by immediate replacement for both the health of those covered by the ACA and the hospitals who serve all Tennesseans. In particular, he warned of the consequences of cutting hospital reimbursements under ACA while leaving in cuts to Medicare, which is addressed under separate legislation. The full statement follows:

"Many Tennesseans covered through the insurance exchange have health coverage for the first time in their lives. This provides them with access to quality, affordable care, whether it's primary, behavioral or hospital care. To lose that coverage would be a tragedy.

"Sen. Corker is absolutely correct when he stated that disruption to the insurance market will only hurt those who would lose their coverage and need it most. That number includes newly covered veterans, children and families.

"Tennessee's rural hospitals in particular, along with those hospitals with high amounts of uncompensated care, are in dire financial straits and rely heavily on revenue as a result of increased health coverage through the ACA. Losing those additional funds would be devastating. At the same time, there are significant cuts mandated by the ACA to hospital Medicare payments in the coming years. Repealing the ACA, while maintaining these cuts, would make a bad situation even worse.

"We know Congress will be thoughtful as it debates the ACA repeal and the impact it could have on taxpayers and hospitals across the nation. THA will continue to work with our delegation to speak on behalf of the Tennesseans who are currently covered under the act as well as the hospitals that serve them." - Craig Becker.

Sen. Alexander

U.S. Senator Lamar Alexander (R-TN), who was just re-elected as chair of the Senate's Committee on Health, Education, Labor and Pensions (HELP) for the second consecutive Congress, has been vocal in his support of simultaneous repeal and replace and has put forth a proposal to do so.

In a speech Tuesday night (Jan. 10) detailing his proposal, Alexander said: "To me, 'simultaneously' and 'concurrently' mean Obamacare should be finally repealed only when there are concrete, practical reforms in place that give Americans access to truly affordable healthcare. The American people deserve healthcare reform that's done in the right way, for the right reasons, in the right amount of time. It's not about developing a quick fix. It's about working toward long-term solutions that works for everyone."

Alexander likened addressing the Obamacare exchanges in Tennessee and across the country to handling a collapsing bridge: "If your local bridge were 'very near collapse,' the first thing you would do is send in a rescue crew to repair it temporarily so no one else is hurt. Then you would build a better bridge, or more accurately, many bridges, as states develop their own plans for providing access to truly affordable healthcare to replace the old bridge. Finally, when the new bridges are finished, you would close the old bridge.

Alexander proposed a three-step plan: "We will first send in a rescue crew to repair temporarily a collapsing healthcare market so no one else is hurt.

"Then, step by step, we will build better systems that give Americans access to truly affordable healthcare. We will do this by moving healthcare decisions out of Washington, D.C., and back to states and patients.

"Finally, when our reforms become concrete, practical alternatives, we will repeal the remaining parts of Obamacare in order to repair the damage it has caused Americans. This is what I believe we mean when we say Obamacare should be repealed and replaced, simultaneously and concurrently."

He went on to say, "Here is what we WILL NOT do:

"This is not the bill for Medicare reform. That will be handled separately. Secondly, you will not be disqualified from getting insurance if you have a pre-existing health condition, and if you are under the age of 26, you will still be able to be covered on your parent's plan."

Alexander then outlined the three steps he said should begin immediately:

"1) The rescue plan -- 6% of Americans with insurance buy their health insurance in the individual market, including the Obamacare exchanges. This is where much of today's turmoil is: higher premiums, higher co-pays and insurers pulling out of markets. While we build a replacement, we want the 11 million Americans who now buy on the exchanges to be able to continue to buy private insurance. This will require Congress and the President to take action before March 1, which is when insurance companies begin to decide whether they will offer insurance in these markets during 2018.

"In general, the goal is to get as close as possible to allowing any state-approved plan to count as health insurance under Obamacare rules, while we are transitioning to new systems. Among actions that will help are to allow individuals to use their existing Obamacare subsidies to purchase state-approve insurance outside Obamacare exchanges; adjust Obamacare's special enrollment periods; approve the temporary continuation of cost sharing subsidies for deductibles and co-pays; allow states more flexibility to determine so-called 'essential health benefits,' age-rating rules and small group restrictions; expand health savings accounts; eventually provide tax credits to help lower income Americans buy insurance; and repeal the individual mandate when new insurance market rules are in place. When the new administration rewrites the guidance on Obamacare section 1332 state innovations waivers to allow for more state flexibility, states will have the authority to further innovate to build more modern health systems.

"2) On employer insurance -- 61% of all Americans who have insurance coverage get it on the job. We will repair the damage Obamacare has done so employers can offer employees more personalized, patient-centered care. We will repeal Obamacare's employer mandate penalty; allow states to determine the so-called 'essential health benefits' and thereby lower costs for small businesses; repeal Obamacare's restrictions on grandfathered health plans, wellness benefits, small group plans, and provide more flexibility for small businesses so they can work together to buy insurance. This will mean more state authority, more choices and lower costs for the 178 million Americans who obtain insurance on the job.

"3) Medicaid -- 22% of all insured Americans are covered by Medicaid. We will give states more flexibility to offer these 62 million citizens more options by making federal Medicaid waivers more flexible."

American College of Physicians

On Jan. 9, the American College of Physicians sent a letter to Congress with a message of "first do no harm."

The APA, representing 148,000 internal medicine physicians (internists), related subspecialists, and medical students, implored Congress to not roll back coverage and protections established by the Affordable Care Act and to evaluate any proposals to change it based on whether or not they would result in improvements in coverage, access and protections for patients.

"Independent and non-partisan analyses show that efforts to 'repeal and replace' the ACA would lead to massive losses of coverage and consumer protections for people enrolled in commercial insurance markets and in the Medicaid program, slow the movement to value-based payment reforms, force seniors to pay more for their prescription drugs, and undermine initiatives to prevent illnesses and promote public health," said Nitin S. Damle, MD, MS, MACP, president of ACP, in the letter. "If the ACA is repealed, every state in the country would experience big increases in the uninsured rate, uncompensated care, and potential loss of coverage for people with pre-existing conditions."

The impact of the threat to patients if the ACA is repealed would be substantial. A 2015 study from the Congressional Budget Office estimated that the full repeal of the ACA would increase federal budget deficits by $137 billion between 2016 and 2025. A 2016 study from the Urban Institute estimates that 58 million U.S. residents would be without insurance coverage if the ACA is repealed. In December 2016 the Kaiser Family Foundation released a study showing that 52 million people under age 65 have a pre-existing condition that would have made them uninsurable in the pre-ACA individual insurance market.

For more information, full text of the letter, and an analysis of the impact in each state, click here.